Book review: Doctors Who Think

ATUL GAWANDE BEGAN his book Complications with a stomach-knotting account of the first time he had to insert a central line into a patient for intravenous feeding. It is a basic hospital procedure but that does not make it easy or risk-free. For a student doctor in his fourth week of training it was a disaster-in-waiting. For his readers, the description of trying to avoid lungs and arteries while stabbing a "big goddam needle" into a man's chest was rivetting medical drama. His point: for all its accumulated advances and expertise, medicine is practised by fallible human beings and things go wrong.

There is no set piece quite as vivid in Gawande's new book, Better. Five years on, he is a general surgeon at the Brigham and Women's Hospital in Boston and an assistant professor at Harvard Medical School. The fresh eyes and uncertainty of the novice are replaced by confidence and a search for solutions. The close-up, personal experiences that amazed him have extended to bigger issues facing modern medicine.

What has not changed is the quality of Gawande's writing. He somehow finds time to retain a staff position with The New Yorker magazine as an elegant essayist on the challenges of his profession. Five chapters of Better began life there, which is probably why the collection struggles slightly to hold together.

Gawande's thesis is simple: many medical problems have human answers. Doctors can serve their patients better by applying diligence, ingenuity and an intention to do right. Bacterial infections that kill hospital patients in alarming numbers worldwide could be wiped out, he argues, if doctors and nurses just washed their hands between patients. The catch is that they are busy and distracted and, with all good intentions, do so only a third to half as often as they should.

But one surgeon in a Pittsburgh hospital found a way to reduce its staphylococcus aureus (golden staph) infection rate to zero. He applied the idea of "positive deviance": rather than nagging staff to change, he built on capabilities they already had. By asking them how to solve the infection problem, he soon had hand-gel dispensers installed in useful places, nurses reminding doctors to wash and careful records of the resulting improvements.

Moving from the everyday to the epidemic, Gawande tracks the campaign to eradicate polio in India. As he reports from a four-wheel-drive rattle-trap, success depends on persistent doctors who visit every residence in scattered communities. Not one child can be missed.

A fascinating chapter reports that casualties of war injuries have dropped from 24 per cent in the Vietnam and Gulf wars to 10 per cent in Afghanistan and Iraq, not because fewer soldiers are wounded but because of "simple, almost banal changes". Surgical teams go with troops into the battlefield and travel time to the US for the seriously injured has been reduced to less than four days from 45 days during the Vietnam War. Gawande credits "a commitment to making a science of performance, rather than waiting for new discoveries".

He writes amusingly but sensitively about how doctors conduct physical examinations. Is the patient naked or clothed? Chaperoned or alone? He explores alternatives to litigation in medical malpractice, wonders how much doctors should be paid and how hard they should fight to save a patient. He tracks down doctors who have transgressed their professional code by assisting at executions. He finds what makes one hospital perform outstandingly in the treatment of cystic fibrosis. In explaining why caesarian section has become the all-purpose solution to difficult births, he looks at the scoring system that measures a baby's condition at birth and suggests a similar measure for all hospital patients.

Gawande writes with clarity, empathy and a strong yet cool point of view. He has a journalist's nose for a provocative angle. If he lacks the eccentric charm of my other favourite doctor-philosopher, Oliver Sacks, he compensates by writing from the frontline of mainstream medicine.

As with Gawande and Sacks, Jerome Groopman writes for The New Yorker and, similarly, he is interested in the personal stories behind the modern medical industry. Not as compelling a stylist as Gawande, the older Groopman is however a wise storyteller in How Doctors Think. Chief of experimental medicine at a Boston medical centre and a professor at Harvard Medical School, he interviewed dozens of peers to illustrate this well-shaped, important book.

As doctors work under pressure and rely on machines and fixed guidelines, Groopman argues, they risk thinking automatically. Physicians interrupt their patients' stories, on average, within 18 seconds. The sickest patients are least liked by doctors and often avoided because they induce feelings of failure. Added to doctors' innate conservatism, these deaf spots can lead to mistreatment, as in the book's first case study.

A woman with digestive problems was dismissed as neurotic by doctors for 15 years until, haggard and emaciated, she found a gastroenterologist who began afresh, observing and listening without prejudice. His diagnosis of coeliac disease, an allergy to gluten, saved her life. (I reached that diagnosis as soon as I read her symptoms but perhaps we are all more familiar with them than when she fell ill 20 years ago.)

Groopman looks at ethical dilemmas, such as the influence of drug companies. There are elements of memoir, too, as he relates his experiences as both doctor and patient. He consulted five specialists about his unusual hand injury and, cautioned by his own expertise, held back from potentially damaging treatments until he saw a young man who questioned the evidence of an MRI and let "a searching mind guide his hands".

Occasionally I questioned Groopman's tendency to praise as heroes the doctors who share his approach and dismiss the unnamed masses as lazy or misinformed. But both these authors include an engaging mea culpa in their critique. They challenge doctors to think originally and yet not act irresponsibly. They also challenge us to be better patients.